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Contractor Section: <br />s��l 6�� - �gs- <br />Vendor Name / Business Name! UEI Number <br />b.��S� ���2 r � <br />State of Washinglon Co r ctor License Number. � <br />��3 � �`� 5-�. S, w . �j�,�c�s ��� �1 ��,� � <br />Vendor Mailing Address City State Zip <br />�� �bs �f1�� A6�1�-�-������s��.��E,��;1.��a., <br />Phone <br />Email <br />I, the Vendor, agree to receive tlie Back�vater Prevention Device rebate check directty for the <br />installation at the above referenced prope�ty address. By agreeing to rer,eive lhe rebate check <br />directiy, I agree to Ihe `ollowing: <br />1. The Backwater Prevenlion Device rebale amount v�ill be deducted from the final invoice <br />given to the propem,� o�vner for the installation at the property address referenced above, if <br />the total cost of ihe installation is greater than the rebate. <br />2. i, the Vendor, am a Washington Slate licensed contractor. <br />3. The City of Everett v✓ill send a Federal Form 1099 MISC to me, the Vendor, for Back�vater <br />Prevenlion Device rebate payments totaling more than 3600 per calendar year, and vrill <br />report the same paymenls to lhe Intemal Revenue Service. <br />I accept the payment of the [iackwater ?revention Device rebate from the City of Eve�ett pending <br />approval of the completed BacMvater Prevention Device rebate package by ;he City of Everett <br />, � <br />Signature cf Contractor <br />�—)� .-a��s— <br />Date <br />